The first nursing associates are being trained in a myriad of different ways and across varying scopes of practice, an investigation by Nursing Times into the controversial new role reveals.
In our first comprehensive check on progress so far with the development of nursing associates, we spoke to those involved with piloting the new role – including trainees, educators and employers.
“These people are very talented but probably haven’t had the opportunity to develop in this way before”
As well as training approaches, the investigation looked at how employers intended to use the role and how it is being received by registrants – having proved a divisive subject for the profession since it was announced in December 2015.
We found programmes were being delivered through a variety of ways across England, with some trainees focusing on fundamental theories behind nursing, while others were also being taught more advanced skills at the same level as student nurses, including use of controlled drugs.
Regulatory standards for the new role are not expected to be finalised by the Nursing and Midwifery Council until the autumn so universities and employers have shaped training according to a previously published curriculum and what their local workforce requires.
The two-year programmes are now half-way through for most of the 2,000 trainees in the pilot phase, which began in 2016.
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Trainees, their course leaders and chief nurses spoke to Nursing Times to explain what skills and knowledge are being taught, the level they expect associates to practise at when qualified, and how they will fit in with nurses and other staff.
At the University of Northampton, first year trainees were taught some elements of a pre-registration nurse degree – such as knowledge of anatomy and physiology, and the principles of evidence-based care. But in their second year they will have more detailed training in areas that student nurses usually only touch on.
“Within our pre-reg degree programme, in the second year there is a lot of field-specific training – so students will look at adult or mental health nursing for example,” said senior nursing lecturer Ruth Smith, who is overseeing training for 38 associates at the university.
“For the associates they are doing a much broader take on that,” she said. “They are looking more closely at things that student nurses do an overview of because of their specialist training…
“This is particularly true for community work and reablement,” she said. ”Part of that is down to our local NHS employers knowing where they want associates to work at the end of the course.”
“We are learning about controlled drugs, but it’s not something we’re wanting to jump into”
Areas of teaching this year will include the application of research and evidence in clinical practice, disease management, mental health, frailty and falls prevention, she noted.
Similar to many other course leaders, Ms Smith said it was still unclear what type of medicines associates would be able to administer until full draft guidance was issued by the NMC in the spring.
Previous plans that associates should be able to give controlled medication, leaked in a draft version of Health Education England’s curriculum in 2016, sparked a wave of criticism due to suggestions of patient safety risks. The reference was subsequently removed from the curriculum.
The NMC’s draft version of standards currently states associates should be able to administer drugs in a safe and effective way and that it is working on further guidelines.
Associates must be able to recognise signs of allergy and adverse reactions and must also be able to demonstrate the ability to safely administer specified medications by a variety of different routes, such as inhalation, topical, oral, subcutaneous, per rectum, add the NMC’s draft standards.
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Associates on the Northampton course have so far been tutored about the management of medication – such as labelling – as well as simulation of how to administer drugs in their first year, but not in practice.
Ms Smith said the university was waiting for the regulator to provide more guidance on this issue, including controlled drugs, before providing further teaching in this area.
However, other course leaders in England are taking a different approach, including at the University of Central Lancashire where associates are being taught the same level of medicines administration as nurses.
“Nursing standards for practice, the NMC code and hospital policy dictates that this is one part of the job where there are no varying levels of practice, in our opinion,” said Karen Wright, head of the school of nursing at Central Lancashire, which is training 39 associates.
“They are my workforce of the future. We have a very clear plan”
Its course also includes tuition about giving controlled drugs, but “whether or not associates will be involved in the administration of controlled drugs is a service decision”, she said.
Denise Baker, head of pre-qualification healthcare at the University of Derby, said trainees had been able to continue administering the same drugs – such as immunisations – while training in their first year – but only if they had previously been doing so as a healthcare assistant, and were working with their own employer.
“If they are working in surgical care or social care, or the community or primary care or mental health, actually, they have an awful lot to do with medication already,” she said. “If you are working in primary or community care you are probably already doing subcutaneous injections. You’re probably already looking after oral medication.
“We recognise it is only really those trainees based in an acute hospital environment that don’t [currently] have a lot to do with medication,” said Ms Baker, who is overseeing a programme of around 120 associates.
“It is only really trainees in acute hospitals that don’t currently have a lot to do with medication”
Those from acute settings had, therefore, been offered “peripheral participation” in their first year, through observing or discussing medicines administration with their supervisor.
In the second year, all associates would be prepared for drugs management according to what their employer expected their responsibilities to be once they qualified, said Ms Baker.
“Even if it does transpire that nursing associates are able to do intravenous drugs, for instance, then we’ve still got to wait for employers to change their protocols and policies before they can do it in practice,” she added.
Ian Costello is a trainee nursing associate with 15 years’ experience as a healthcare assistant within a forensic learning disability unit. He is based at Hertfordshire Partnership NHS Foundation Trust and studying at the University of Hertfordshire.
During his first year he has been observing drugs rounds while on placement to understand legal issues, such as consent, maximum dosages and when to refer to more senior members of staff. He is also being taught about the use of controlled drugs.
“Because it’s a pilot scheme and the NMC didn’t write the requirements for this particular pilot, we are learning about controlled drugs, including the checking and ordering. But it’s not something we’re wanting to jump into,” he said.
But upon qualification he told Nursing Times he would avoid administering medication unless it was an emergency because to him “there is more to nursing than giving medication”.
If it did end up being a core requirement of the role to administer medication, Mr Costello said he and other trainees believed nursing associates should be paid a salary that overlaps band 4 and band 5 wages in the NHS.
“This would take into consideration that we are probably going to be paying the same £120 registration fee to the NMC as nurses – and the fact you have assistant practitioners at band 4 who don’t give medication, and HCAs in the community who won’t have the same level of education,” he added.
While he is passionate about the nursing associate role, Mr Costello said he eventually wants to become a nurse by going on to complete the additional training that it is hoped many will do.
This is the aim of Barking, Havering and Redbridge University Hospitals NHS Trust chief nurse Kathryn Halford, who wants to see all associates at her organisation go on to train as registered nurses. “If you speak to our associates, at the end of their first year they will say in three and a half years’ time I will be a registered nurse on a ward,” she said.
The organisation is currently working alongside Barts Health NHS Trust and North East London NHS Trust as part of a pilot site with 57 trainees. It is also planning to train 60 more throughout 2018, starting from January, through a new apprenticeship being developed in England.
While the training is similar to that of nurses – and associates would be practising administering drugs once the NMC had outlined its requirements – Ms Halford stressed she would not be removing nurse vacancies and substituting with associates.
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“There is absolutely no way I would take out a band 5 post and put a band 4 in. Their contribution is they are my workforce of the future. We have a very clear plan that they can do two years of nursing associate training, six months of consolidation and then 18-24 months top up nurse training,” she said.
Some trainees are worried they will be used in place of nurses though, and that they will be asked to complete tasks outside of their scope of practice.
“I have got concerns because sometimes, within all hospitals, there don’t seem to be enough band 5 nurses to go around,” said trainee associate Louise Bromwich, who is studying at Coventry University.
“But it’s about us recognising what we can do and can’t do. I’m going to be very conscious of what I’m allowed to do with my PIN,” said Ms Bromwich, who has six years’ experience as an HCA at University Hospitals Coventry and Warwickshire NHS Trust, where she is also training.
For Julie Attenborough, associate dean at City University, which is part of a pilot site with other universities in London that has 124 trainees, it is registered nurses who require more training about what they can delegate.
“We cover the parameters of the role with associates and how they will work alongside nurses, which is really important,” she said. “I think personally the work needs to happen with the nurse curriculum around that. Associates understand very well what the delegation might be.”
One of the ongoing challenges has been a lack of understanding among nurses about the new role – and has led to some feelings of animosity, according to 60-year-old trainee Jed Bates, who is based at North West Anglia NHS Foundation Trust.
“There’s been a lot of negative feedback on social media from registered nurses about the role. So I think for the first 12 months after qualifying it will be up to us to prove our worth,” he said.
“There have been lots of comments about ‘nursing on the cheap’ and it’s not true. These are skills we are being taught to support registered nurses,” added Mr Bates, who has experience as an assistant within the ambulance service and as an HCA.
Not all associates have experienced this reception. At Bolton NHS Foundation Trust, trainee Kimberly Kelly, who has 11 years’ experience as an HCA and also has a psychology degree, said registered nurses “can’t wait for us to become nursing associates because they can already feel the benefit”.
“We are there as an extra member of staff to complement the nursing workforce and help take some of their extra workload off,” she added.
An announcement by the heath secretary last year revealed a further 5,000 associates are expected to begin training in 2018 across England – when programmes become apprenticeships – and 7,500 every year onwards.
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Directors of nursing are keen to see more trained, but it has been warned it will take some time before associates can make a significant difference to workforce models.
“In reality we have a workforce model at the moment that is not reliant on nursing associates, even when they come out at the end of training of this second year,” said Northern Devon Healthcare NHS Trust’s chief nurse Darryn Allcorn.
He said his organisation, which has 15 trainees on the pilot programme and expects to train 15 more as apprentices in 2018, will require a “critical mass to make this work” that will take at least 18 months.
“What we don’t want is that on a Monday/Tuesday/Wednesday, we ‘ve got this model and skill mix with nursing associates, and then for the rest of the week we haven’t got enough of them to staff it,” he said.
“For us the hardest challenge will be how we support associates to maintain their skills and competencies while we are getting the critical mass to make this a real part of the workforce, rather than a token few here and there,” he added.
While finding enough placements and tutors to train even more may be a challenge across the country, attracting people who want to move into the role is not expected to be a problem, based on the pilot.
“People have been very committed to the programme,” said City University’s Julie Attenborough. “It’s one of the most humbling things as an academic that I’ve ever witnessed to listen to those trainees talking about their experiences. These people are very talented but probably haven’t had the opportunity to develop in this way before.”
An NMC spokesman said that while training programmes for associates may differ, the most important requirement would be for associates to meet the regulator’s standards before being able to join its register.
“Last year, we released an early working draft of the nursing associate standards so that test sites and trainees can familiarise themselves with the likely standards that nursing associates will need to meet to join our register.
“Only those trainees that meet our standards will be able to join our register and there will be a robust quality assurance process in place to ensure this is the case,” he added.
- This is part of a two-part Nursing Times investigation into the current state of play on nursing associates
- Don’t miss our exclusive interview with the chair of nursing associate scrutiny group on the role’s safety